Tag Archives: Citalopram

Today is the day.

Today is the day: my first counselling session. I would like to write about how I feel, but truthfully, I don’t feel anything. It’s been nearly five months coming, and today, I feel much like I did five months ago. Numb. Empty. And exhausted. Exhausted by the daily grind of depression, the heaviness of trying to get out of bed, the dissonance of putting on an enthusiastic face for the outside world, and the pressure of wanting to be ‘getting better’ for the people in my life who were so relieved to see me getting professional help.

I ran out of citalopram a week ago and can’t find the prescription slip to order a repeat. I could go back to my GP to get a new prescription,  but I’ve explained to myself that since I didn’t want to be on medication anyway, this is a good opportunity to see whether psychological treatment alone is enough. That’s the rational explanation. The truth is, the thought of seeing him again makes my heart beat through my chest, so I’m avoiding it.

Now today, I have to talk. But what to say? My life is good. I have a well paid, interesting job; a partner who I love deeply and have fun with; a nice flat in an area lots of people wish they could live in; good relationships with family; and lots of friends who I love and who care about me. There is no good reason for me to be unhappy. I could dig out supposedly traumatic events from throughout my life, but in my experience, that’s true of pretty much everyone. So that leaves me back where I started: what to talk about? In my last go at psychological treatment, I remember endless silences because I didn’t know what I was meant to talk about.

A couple of months ago, I requested a copy of my patient file from the psychiatrist I saw in 2004-5. It was hard seeing things written down about myself, things that I didn’t recall being spoken in the room. Words like “anorexia nervosa: partial remission”, “drunk today”, “borderline personality traits: see for further assessment”. There were also the letters between my psychiatrist and my GP, which I’d not seen before.

I feel she is suffering from a mild to moderate Borderline Personality Disorder. She describes a long history of labile mood, and has been self lacerating for the 2 years. She also bites her fingers to cause pain, and can also be reckless with spending and sex.

And a year later:

If she remains engaged in therapy she should continue to make slow but steady progress.

I dropped out of treatment a month after that last letter was written.

I feel reassured that this time I am seeing a counsellor without an official referral from my GP, so they won’t share information about me. But I know I suggested in an earlier post that it would be useful for them to share information. The point is, I want information shared in a way that includes me. I want professionals who are collaborating in my treatment with me. If they communicate, I should be copied in. Instead, I get a choice between uncoordinated treatment from two separate professionals who don’t know what the other is doing, or coordinated treatment in which I have no voice.

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Waiting times.

It’s a month since my counselling assessment and I’m still waiting for my first session. I expect to wait another month, until the first week of March, but I haven’t had a letter yet to confirm when that appointment will be. It’s two months since I first went to the GP about my mental health (or 21 months, if I count it from the actual first time I went, but was too anxious to disclose).

Before that first GP appointment, I wrote:

I expect that I will either not be offered any help, or if I am, it will be either antidepressants or a referral for a few sessions of CBT that I may have to wait months for.

The reality hasn’t been that far off my low expectations and I’m starting to wonder why I even bothered. I’m pleased that I’ve been offered integrative counselling, not CBT, but the wait for it to start is draining and I’m ambivalent about the antidepressants after taking them for two months.

At my last appointment, the GP told me to come back in three months, but that I could come back earlier if I needed to. I don’t know what that means though. How bad does it need to be for me to come back? I’m feeling worse again, but then depression does go up and down anyway, and I’m not sure whether I should expect that pattern to be different on medication? And what will the GP have to offer anyway, besides an increased dosage?

I’m also concerned that the Citalopram is now making things worse. I’ve been having night sweats; I get them anyway, but now they’re almost every night. I wake up between 3 and 4am, throwing off soaking bedsheets, slippery with sweat, my heart pounding and feeling terrified. It’s not easy to get back to sleep after that. This leaves me exhausted during the day, exacerbating the feeling of concrete in my limbs.

In seeking professional help, I was under no illusions that I would receive high quality treatment. What I’m surprised to realise now though, is that despite that, I didn’t really have a plan for what I would do when my low expectations were realised. I think I still thought that after trying unsuccessfully to treat myself for so long, professional help would be the answer. I would get help, and although it might take time, I would be moving towards recovery.

Now I’m not so sure. My suicidal ideation has pretty much stopped, which is good, but beyond that I can’t see any real gains. I’m sure that eventually I will get to see a counsellor, but right now I feel isolated and more lost than before seeking help. At least then, I still had my psychological ‘last resort’ of seeking treatment.

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Six weeks on Citalopram.

It’s six weeks since I started taking Citalopram. As I’ve mentioned, I track my mood on Mappiness. The graph below shows how happy, relaxed and awake I’ve felt between the end of November and mid January. Overall, I think there’s been a slight improvement, although it’s not particularly clear.

Mappiness 2012-13

A comparison to the same period last year provides even less clarity (there’s more data here, as I was tracking twice a day): I had a more pronounced upward trajectory this time last year, when I wasn’t on medication.

Mappiness 11-12

I saw the GP for a second follow-up on Thursday and mentioned that although I felt a bit better, I had noticed a similar pattern last year so wasn’t confident the change was due to medication. He didn’t really accept that explanation:

GP: I mean it can be a combination of things. Normally around the winter months, there’s less sunshine of-course, it affects people’s moods. And if you are pre-disposed to developing low moods anyway, probably it can make it a bit, exaggerate its effect. Now, ah, the other thing about the tablets is that ah, sometimes you don’t see the effect because it’s so gradual and what tends to happen is the only time that people realise it’s working is when they come off, and then they realise that it was working. So I think, you know, they’re actually working.

It’s winter now and I was telling him that I’m feeling a bit better, so his explanation made me feel that he wasn’t listening. From our previous conversations, I feel like he is very confident in the efficacy of SSRIs and that it would be very difficult to change that belief.

I’ve also felt in my two follow-up appointments that he’s not really interested in psychological treatments, and has only offered it as a complementary treatment because I wanted it. This time, I don’t think he would have even checked in about the counselling he’d referred me for, except that I brought it up.

GP: You still feel bad about yourself, self esteem?

Me: Yeah, that’s, yeah that’s still there. I’m gonna start counselling with Mind, but that’s not for a few weeks.

GP: Okay, okay. You managed to get hold of them.

Me: Yeah, yeah. So I had my assessment but I’ve just got to wait for them to allocate me a counsellor.

GP: Right. Great. Concentration?

He didn’t change my Citalopram dose, but gave me a repeat prescription and told me to come back in 3 months. I left my third appointment feeling frustrated. In my own line of work (a different health field), we talk constantly of “partnership-working”. In my first appointment, the GP gave me the phone number for Mind, but he drastically under-estimated how long I’d really have to wait to access counselling, didn’t know they offered evening appointments nor the actual cost, and he couldn’t tell me what type of counselling they offered. Now, he knows I’ve accessed the service but he’s not interested in knowing anything more.

It strikes me that once I start counselling, my counsellor will probably have the best insight into how my mood is changing. But there will be no discussions between my counsellor, my GP and I about these changes and my medication. This leaves me stuck in the middle, responsible for coordinating my treatment, and trying to communicate with a GP who believes that antidepressants are the best answer.

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What happened next.

I went for my first GP appointment three weeks ago, you can read the full transcript here. Overall, it was more positive than I had hoped for. The GP was sensitive and took me seriously, and I was pleased to be offered counselling. I felt a bit pressured into taking antidepressants, and that he wasn’t really open to engaging with my concerns about medication. I also felt it would have been helpful if he’d been a bit more informed about the service that Mind offers, in particular what type of counselling it is (I’m assuming CBT) and whether they offer out-of-hours appointments.

The day after my appointment, I called Mind during my lunchbreak. The receptionist put me through to the counselling team and their phone number rang through to voicemail, so I left a message.

The following afternoon I still hadn’t had  a callback from Mind. I was feeling numb and tired; I had the Citalopram prescription sitting in my bag. I hadn’t thought I would ever take antidepressants again, but the lack of a call-back about counselling made me think that that could be a long process and I’d already waited so long to seek help. Although I know medication can be harmful, I hadn’t had unmanageable side effects previously and this was a significantly lower dose than I’d been on in the past (10mg compared with 40mg), so I figured I’d give it a go.

I filled the prescription and started taking it the next morning. After problems with extreme tiredness – falling asleep by 9pm every night – I switched to taking the medication in the evening. I then started having problems with waking up very early, which I thought may have been a side effect but the GP later explained that this isn’t a known side effect and my sleeping problems are most likely just due to the depression.

Twelve days after beginning on Citalopram I had my follow-up appointment. This time it was very brief. I’d had a blood test in the interim with a lovely nurse (a Bangladeshi doctor who was working through her qualifications to become a doctor in the UK) and the GP confirmed that I’m not even remotely anaemic. He asked how the medication was going, and I replied that so far I’d not noticed any difference. He didn’t ask about the counselling, but I volunteered that I now had an initial assessment booked for 7th January. He asked that I make an appointment with him for another month’s time and if I’m feeling a bit better but not a lot, then he will increase the Citalopram dose.

I also asked how he had made the decision to put me on Citalopram and not something else. He replied that GPs generally now prescribe SSRIs instead of the older TCAs, and its usually Sertraline or Citalopram. I said that I understood that, but wanted to know how he decided on Citalopram rather than Sertraline or something else such as Escitalopram. He explained that it really just comes down to professional experience, and that he’s had good results on Citalopram with his patients. He added that Escitalopram is expensive, so it would never be the first choice. This seems to be broadly in line with the NICE Guidance, which is fine, but I am left with the feeling that my GP views antidepressants as the central treatment option, with counselling as a slightly hippy-ish add-on.

It’s now just over three weeks since my first appointment. I’ve had some days of feeling quite a bit better, but today I’m feeling quite a lot worse, and I never know whether to attribute any gains to treatment or not. While Christmas is hard for many people, it’s a good time of year for me and I always feel better with time off work spent with loved ones, cooking for them and socialising. Today is the first day that all my family have gone home, and the numbness has descended again.

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My first GP appointment, transcribed.

Two weeks ago, I went to see the GP about my mental health for the first time in 7 years and I decided to audio record the interview. I was conscious that my memory of what happened would be influenced by my experience of it, so I wanted a more objective record of exactly how it went. And I wanted to be able to share it here, to give a better account of how it happened. This is my experience, not necessarily a representation of the service anyone else would get from a doctor in their local NHS practice, but it’s one example.

—————————————————————————————————————————

GP: Hi, come in.

Me: Hi.

GP: Hi, take a seat. [inaudible].

Me: Um. [pause]. I’ve had low mood for about 18 months now and I’m just a bit tired so [laughs], I thought I’d come to the GP and talk about it and see if there’s anything I can do.

GP: Okay. So what’s been going on?

Me: Um [sighs]. I don’t know if there’s anything in particular that’s been going on, it’s just, um [pause], yeah, I dunno, it’s just kind of [pause] continuous, so I don’t know [laughs].

GP: Right.

Me: It kind of goes up and down and it’s not as bad as it has been, but…

GP: Hmm.

Me: Um, I think, last time I came to the GP it was a while ago…

GP: Yep.

Me: I was going to talk about it then but I didn’t feel able to…

GP: Right.

Me: So it’s taken me a while to come back.

GP: Okay, right.

Me: Um. [pause] I’ve had depression in the past but that was quite a while ago.

GP: Okay. Were you on medication?

Me: Yeah. I was on Zoloft, and then on Citalopram.

GP: Okay. And how long was the treatment for?

Me: Um, it was probably, I think I was on it for a couple of years.

GP: Right, okay. And then did you finish the last treatment?

Me: Um, it was 2005.

GP: 2005?

Me: Yeah, a long time ago.

GP: So you’ve been okay since then?

Me: Yeah, ah, yeah, I’ve been okay, yeah. I was fine for a long time and so, yeah.

GP: Okay. So when did this current low mood start?

Me: Um, about 18 months ago.

GP: And ah, are you able to sleep okay?

Me: Um, it, it comes and goes. It’s not so bad at the moment, but it, sometimes it, I’ll wake up in the night. Like I’m fine falling asleep, but it’s just that I wake up quite early.

GP: Right, okay. So how many hours of sleep would you say you get?

Me: Um. At the moment it’s okay, I’m getting about 7 hours of sleep at the moment…

GP: Right, okay.

Me: But other times it will be 4 or 5.

GP: Right, okay. And your appetite?

Me: Appetite is fine.

GP: [inaudible]

Me: Ah, I have lost a bit of weight, but I think that’s just because I’ve been exercising.

GP: Okay, okay. Right. And any thoughts of self harm?

Me: Ah [pause]. I think about it but it’s not something I’m doing.

GP: Right. How often do you think about it?

Me: [pause] Um. Quite a lot, like it’s always sort of there, but I.

GP: Okay, right. But you haven’t got, haven’t got any kind of plans or anything? No? Okay. But have you self harmed, cut yourself or…?

Me: I have in the past, but not this time.

GP: Not now, okay. Are you in a relationship currently?

Me: Yes.

GP: And does he support you?

Me: Yeah. I’ve spoken to my partner about it, but only recently.

GP: [inaudible] right. Now, how are your energy levels?

Me: Not great [laughs]

GP: Right.

Me: I’ve just got that feeling of being kind of heavy, all the time.

GP: Right, yeah, okay. Are you enjoying things you normally enjoy, like going out with friends and things?

Me: Not really. Like, yeah [pause]. Not as much as, everything’s just more of an effort.

GP: Right, okay, okay.

Me: [inaudible]

GP: And alcohol?

Me: Um, I’ve been managing it, it’s not too, yeah. I probably should drink less.

GP: Ah okay, right. Drugs…?

Me: No.

GP: Smoking?

Me: Oh smoking, yeah.

GP: Right, okay. Now, um, the other thing is that obviously, you know, with a history of depression and the way you are feeling as well, I think you would know [inaudible]. Now compared to the last time you started on medication…

Me: Yeah?

GP: Do you think you are feeling the same or getting towards feeling, you know, the same again?

Me: Um [pause], yeah, it’s pretty similar.

GP: Okay. Did you have any counselling or…?

Me: Yeah.

GP: You did? Okay, right. Did you find it helpful?

Me: Um [pause]. Not [pause] hmm. I, well, I had counselling and then I was referred to a psychiatrist as well…

GP: Right.

Me: It [pause]. Yeah. I think I would like counselling again, but I didn’t have a very good relationship with my psychiatrist.

GP: Right, okay. Yes. Now, with the counselling, we can refer you to our psychologist.

Me: Mmm.

GP: And the waiting period is normally a couple of months or something.

Me: Okay.

GP: But then there’s a, a place called Mind.

Me: Yeah, I know Mind.

GP: Then they can give you, you know [inaudible]. And they charge, I think it’s £5 a session.

Me: Okay, so it’s not expensive.

GP:  So I can actually give you their number, and then if you would like I could [inaudible] probably you can do…

Me: Right, okay. I might give Mind a go.

GP: Yes, you’ll get in quicker.

Me: What sort of counselling is it?

GP: Ah, I think it’s one-on-one, yeah [inaudible] they decide the number of sessions you need to do, and then in combination with that kind of treatment I think maybe we’ll start you on some antidepressants as well.

Me: Okay.

GP: Because the last time we saw you was May last year, and if at the time you were having these issues and you couldn’t talk about it and it’s still the same now, then I think we should start you on some Citalopram maybe?

Me: Okay.

GP: But it depends on you, if you want to give the counselling a go first or whether…

Me: Yeah.

GP: …or do you want to, it depends on how you feel, you know?

Me: Yeah.

GP: The thing is, I think that you are probably moderately depressed.

Me: Mmm.

GP: And drug treatment may be beneficial.

Me: Yeah. I suppose I’m not quite sure about antidepressants, I’m sort of [pause]. Yeah. Are they really effective or not, you know?

GP: Yeah they are, they are. Because for somebody who’s had depression in the past, sometimes there could be a physiological reason, or an underlying cause for it.

Me: Yeah.

GP: And it’s due to the seratonin production. Sometimes, for some reason it does not produce enough, and if it does not produce enough, there’s nothing you can do. You can try everything to lift up your mood, but it still doesn’t [inaudible]. Your body for some reason doesn’t produce enough serotonin, so therefore when you do take the medication it stops the breakdown of seratonin and therefore you take that and it elevates the mood. So it will help. The thing is, ah, [pause] you know that people, some people think, oh well it’s…

Me: It’s not a happy pill!

GP: Yeah. But we find, it depends [inaudible] initially it takes about two weeks for it to kick in and then it starts to accumulate and then the way that people realise that, you know, its effect, is when they stop.

Me: Yeah.

GP: Sometimes they’ve been taking it for a while and they’re feeling alright and then they stop and when they start getting depressed again they know, that’s when they realise it was working.

Me: Yeah.

GP: So it’s a slow, you know, kind of treatment. It takes time to build it up. But it depends if you want to give Mind a go first, or whether you want to start, you know, on the antidepressants.

Me: Um. And Mind, they usually don’t have a waiting time, is that?

GP: Ah, I think, Mind’s probably shorter than our psychologist. A week or two.

Me: Ah, okay.

GP: So if you like, you can wait and see them, that would be fine.

Me: And do they have, do you know, do they have appointments only in office hours, or..?

GP: I think probably. I think it’s probably that, 9 to 5. I mean you’ll find all the psychologists will be in office hours.

Me: Yeah. It’s a bit hard for me.

GP: Yeah.

Me: I don’t like, telling people at work that…

GP: Yeah. So that’s what it is. Now ah, it’s entirely, I think you know maybe the antidepressants are [inaudible]. Because you’ve got a strong history, a past history of depression, I think you know you may benefit from, ah, [inaudible].

Me: Mmm. [pause] Can I take a prescription and then…

GP: Yeah, I can give you a prescription now, start you out on the lowest dose, and then I’d like to see you in a couple of weeks time.

Me: Okay.

GP: And see how you’re getting on [inaudible].

Me: Yeah, okay. Thank you.

[GP typing]

GP: Are you on the pill?

Me: No. I’ve got the coil.

GP: Ah, okay. And how are your periods?

Me: Yeah, they’re fine.

GP: Not heavy at all?

Me: No, they are. But it’s been like that since I got the coil.

GP: Mmm, riiight. Because you look a bit pale to me, you know, you may have anaemia or…

[checks my eyes]

GP: Are you feeling more tired than usual?

Me: Yeah.

GP: I think we’ll just get a blood test done to check your iron levels.

Me: Okay.

GP: Because sometimes a combination of factors, you know, can actually affect your mood. You know, being tired already from iron deficiency, and that can also make your mood a bit lower.

Me: Mmm, okay.

[GP writing]

GP: And how’s your self esteem? Your confidence?

Me: Mmm, could be better [laughs]

[GP typing]

GP: Do you know which antidepressants you were on in the past?

Me: Yeah, I was on Zoloft to start with, then I changed to Citalopram.

GP: Right, okay.

[GP printing prescription]

GP: Now the Citalopram is one a day. If you take it during the day and you feel, you know, a bit tired, then take it in the evening.

Me: Okay.

GP: And then let me get you the number for Mind.

[pause]

GP: [inaudible]

Me: Okay

GP: That’s the Citalopram, 10mg is the lowest dose, and I will see you in a couple of weeks.

Me: Okay, alright, thank you.

GP: Okay

[inaudible short conversation as I’m getting up to leave]

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